S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  5845

                       2011-2012 Regular Sessions

                            I N  S E N A T E

                              June 22, 2011
                               ___________

Introduced  by COMMITTEE ON RULES -- read twice and ordered printed, and
  when printed to be committed to the Committee on Rules

AN ACT to amend the insurance law,  in  relation  to  coverage  for  the
  screening, diagnosis and treatment of autism spectrum disorder; and to
  amend  a chapter of the laws of 2011 amending the insurance law relat-
  ing to coverage for the screening, diagnosis and treatment  of  autism
  spectrum  disorder,  as proposed in legislative bill numbers S. 4005-A
  and A. 6305-A, in relation to the effectiveness of such chapter

  THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section 1. Subparagraphs (B) and (C) of paragraph 25 of subsection (i)
of  section 3216 of the insurance law, as added by a chapter of the laws
of 2011 amending the insurance law relating to coverage for the  screen-
ing, diagnosis and treatment of autism spectrum disorder, as proposed in
legislative bill numbers S. 4005-A and A. 6305-A, are amended to read as
follows:
  (B)  Every  policy  which  provides physician services, medical, major
medical or similar comprehensive-type coverage  shall  provide  coverage
for  the  screening, diagnosis and treatment of autism spectrum disorder
in accordance with this paragraph and shall not exclude coverage for the
screening,  diagnosis  or  treatment  of  medical  conditions  otherwise
covered  by  the  policy because the individual is diagnosed with autism
spectrum disorder. Such coverage may be subject to  annual  deductibles,
copayments  and  coinsurance  as may be deemed appropriate by the super-
intendent and shall be consistent with those imposed on  other  benefits
under  the  policy.    COVERAGE  FOR  APPLIED BEHAVIOR ANALYSIS SHALL BE
SUBJECT TO A MAXIMUM BENEFIT OF FORTY-FIVE THOUSAND DOLLARS PER YEAR PER
COVERED INDIVIDUAL AND SUCH MAXIMUM ANNUAL BENEFIT WILL INCREASE BY  THE
AMOUNT  CALCULATED FROM THE AVERAGE TEN YEAR ROLLING AVERAGE INCREASE OF
THE MEDICAL COMPONENT OF THE CONSUMER PRICE INDEX. This paragraph  shall
not  be  construed as limiting the benefits that are otherwise available

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD12076-04-1
              

S. 5845                             2

to an individual under the policy, provided  however  that  such  policy
shall  not  contain any limitations on visits that are solely applied to
the treatment of autism spectrum disorder. No  insurer  shall  terminate
coverage  or  refuse to deliver, execute, issue, amend, adjust, or renew
coverage to an individual solely because  the  individual  is  diagnosed
with autism spectrum disorder or has received treatment for autism spec-
trum  disorder.  Coverage  shall  be  subject  to utilization review and
external appeals of health care services pursuant to article  forty-nine
of  this  chapter  as  well  as, case management, and other managed care
provisions.
  (C) For purposes of this paragraph:
  (i) "autism  spectrum  disorder"  means  any  pervasive  developmental
disorder  as  defined  in  the most recent edition of the diagnostic and
statistical manual of mental  disorders,  including  autistic  disorder,
Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
or pervasive developmental disorder not otherwise specified (PDD-NOS).
  (ii) "applied behavior analysis" means the design, implementation, and
evaluation  of environmental modifications, using behavioral stimuli and
consequences, to  produce  socially  significant  improvement  in  human
behavior,  including  the  use  of  direct observation, measurement, and
functional analysis of the relationship between environment  and  behav-
ior.
  (iii)  "behavioral  health  treatment"  means counseling and treatment
programs, when provided by a licensed  provider,  and  applied  behavior
analysis,  when  provided  or supervised by a behavior analyst certified
pursuant to the behavior analyst certification board, that are necessary
to develop, maintain, or restore, to the maximum extent practicable, the
functioning of an individual. Individuals that provide behavioral health
treatment under the supervision of a certified behavior analyst pursuant
to this paragraph shall be  subject  to  standards  of  professionalism,
SUPERVISION  and relevant experience pursuant to regulations promulgated
by the superintendent in consultation with  the  [commissioner]  COMMIS-
SIONERS of health AND EDUCATION.
  (iv) "diagnosis of autism spectrum disorder" means assessments, evalu-
ations,  or  tests to diagnose whether an individual has autism spectrum
disorder.
  (v) "pharmacy care" means medications prescribed by a licensed  health
care  provider  legally authorized to prescribe under title eight of the
education law.
  (vi) "psychiatric care" means direct or consultative services provided
by a psychiatrist licensed in the state in which the psychiatrist  prac-
tices.
  (vii)  "psychological  care"  means  direct  or  consultative services
provided by a psychologist licensed in the state in which  the  psychol-
ogist practices.
  (viii)  "therapeutic  care"  means  services  provided  by licensed or
certified speech therapists, occupational therapists, social workers, or
physical therapists.
  (ix) "treatment of autism spectrum disorder" shall include the follow-
ing  care  and  [related  equipment]  ASSISTIVE  COMMUNICATION   DEVICES
prescribed  or  ordered for an individual diagnosed with autism spectrum
disorder by a licensed physician or a licensed psychologist:
  (1) behavioral health treatment;
  (2) psychiatric care;
  (3) psychological care;
  (4) medical care provided by a licensed health care provider;

S. 5845                             3

  (5) therapeutic care, including therapeutic care which is deemed habi-
litative or nonrestorative, in the event that the policy provides cover-
age for therapeutic care; and
  (6)  pharmacy  care in the event that the policy provides coverage for
prescription drugs.
  S 2. Subparagraphs (B) and (C) of paragraph 17 of  subsection  (l)  of
section  3221 of the insurance law, as added by a chapter of the laws of
2011 amending the insurance law relating to coverage for the  screening,
diagnosis  and  treatment  of  autism  spectrum disorder, as proposed in
legislative bill numbers S. 4005-A and A. 6305-A, are amended to read as
follows:
  (B) Every group or blanket policy which provides  physician  services,
medical,  major  medical  or  similar  comprehensive-type coverage shall
provide coverage for the screening, diagnosis and  treatment  of  autism
spectrum  disorder  in  accordance  with  this  paragraph  and shall not
exclude coverage for the screening, diagnosis or  treatment  of  medical
conditions  otherwise  covered  by  the policy because the individual is
diagnosed with autism spectrum disorder. Such coverage may be subject to
annual deductibles, copayments and coinsurance as may be  deemed  appro-
priate  by the superintendent and shall be consistent with those imposed
on other benefits under the group  or  blanket  policy.    COVERAGE  FOR
APPLIED  BEHAVIOR  ANALYSIS  SHALL  BE  SUBJECT  TO A MAXIMUM BENEFIT OF
FORTY-FIVE THOUSAND DOLLARS PER YEAR PER  COVERED  INDIVIDUAL  AND  SUCH
MAXIMUM  ANNUAL  BENEFIT WILL INCREASE BY THE AMOUNT CALCULATED FROM THE
AVERAGE TEN YEAR ROLLING AVERAGE INCREASE OF THE  MEDICAL  COMPONENT  OF
THE  CONSUMER  PRICE  INDEX.  This  paragraph  shall not be construed as
limiting the benefits that are  otherwise  available  to  an  individual
under  the  group  or  blanket policy, provided however that such policy
shall not contain any limitations on visits that are solely  applied  to
the  treatment  of  autism spectrum disorder. No insurer shall terminate
coverage or refuse to deliver, execute, issue, amend, adjust,  or  renew
coverage  to  an  individual  solely because the individual is diagnosed
with autism spectrum disorder or has received treatment for autism spec-
trum disorder. Coverage shall  be  subject  to  utilization  review  and
external  appeals of health care services pursuant to article forty-nine
of this chapter as well as, case  management,  and  other  managed  care
provisions.
  (C) For purposes of this paragraph:
  (i)  "autism  spectrum  disorder"  means  any  pervasive developmental
disorder as defined in the most recent edition  of  the  diagnostic  and
statistical  manual  of  mental  disorders, including autistic disorder,
Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
or pervasive developmental disorder not otherwise specified (PDD-NOS).
  (ii) "applied behavior analysis" means the design, implementation, and
evaluation of environmental modifications, using behavioral stimuli  and
consequences,  to  produce  socially  significant  improvement  in human
behavior, including the use  of  direct  observation,  measurement,  and
functional  analysis  of the relationship between environment and behav-
ior.
  (iii) "behavioral health treatment"  means  counseling  and  treatment
programs,  when  provided  by  a licensed provider, and applied behavior
analysis, when provided or supervised by a  behavior  analyst  certified
pursuant to the behavior analyst certification board, that are necessary
to develop, maintain, or restore, to the maximum extent practicable, the
functioning of an individual. Individuals that provide behavioral health
treatment under the supervision of a certified behavior analyst pursuant

S. 5845                             4

to  this  paragraph  shall  be  subject to standards of professionalism,
SUPERVISION and relevant experience pursuant to regulations  promulgated
by  the  superintendent  in consultation with the [commissioner] COMMIS-
SIONERS of health AND EDUCATION.
  (iv) "diagnosis of autism spectrum disorder" means assessments, evalu-
ations,  or  tests to diagnose whether an individual has autism spectrum
disorder.
  (v) "pharmacy care" means medications prescribed by a licensed  health
care  provider  legally authorized to prescribe under title eight of the
education law.
  (vi) "psychiatric care" means direct or consultative services provided
by a psychiatrist licensed in the state in which the psychiatrist  prac-
tices.
  (vii)  "psychological  care"  means  direct  or  consultative services
provided by a psychologist licensed in the state in which  the  psychol-
ogist practices.
  (viii)  "therapeutic  care"  means  services  provided  by licensed or
certified speech therapists, occupational therapists, social workers, or
physical therapists.
  (ix) "treatment of autism spectrum disorder" shall include the follow-
ing  care  and  [related  equipment]  ASSISTIVE  COMMUNICATION   DEVICES
prescribed  or  ordered for an individual diagnosed with autism spectrum
disorder by a licensed physician or a licensed psychologist:
  (1) behavioral health treatment;
  (2) psychiatric care;
  (3) psychological care;
  (4) medical care provided by a licensed health care provider;
  (5) therapeutic care, including therapeutic care which is deemed habi-
litative or nonrestorative, in the event that the policy provides cover-
age for therapeutic care; and
  (6) pharmacy care in the event that the policy provides  coverage  for
prescription drugs.
  S 3. Subsection (ee) of section 4303 of the insurance law, as added by
a  chapter  of  the  laws of 2011 amending the insurance law relating to
coverage for the screening, diagnosis and treatment of  autism  spectrum
disorder,  as  proposed  in  legislative  bill  numbers S. 4005-A and A.
6305-A, is amended to read as follows:
  (ee) (1) A medical expense indemnity corporation, a  hospital  service
corporation  or a health service corporation which provides coverage for
hospital or surgical  care  coverage  shall  not  exclude  coverage  for
screening,  diagnosis  and  treatment  of  medical  conditions otherwise
covered by  the  [policy]  CONTRACT  solely  because  the  treatment  is
provided to diagnose or treat autism spectrum disorder.
  (2)   Every  [policy]  CONTRACT  which  provides  physician  services,
medical, major medical  or  similar  comprehensive-type  coverage  shall
provide  coverage  for  the screening, diagnosis and treatment of autism
spectrum disorder in accordance  with  this  subsection  and  shall  not
exclude  coverage  for  the screening, diagnosis or treatment of medical
conditions otherwise covered by the [policy] CONTRACT because the  indi-
vidual  is diagnosed with autism spectrum disorder. Such coverage may be
subject to annual deductibles, copayments  and  coinsurance  as  may  be
deemed  appropriate  by  the superintendent and shall be consistent with
those imposed on other benefits under the [policy] CONTRACT.    COVERAGE
FOR  APPLIED  BEHAVIOR ANALYSIS SHALL BE SUBJECT TO A MAXIMUM BENEFIT OF
FORTY-FIVE THOUSAND DOLLARS PER YEAR PER  COVERED  INDIVIDUAL  AND  SUCH
MAXIMUM  ANNUAL  BENEFIT WILL INCREASE BY THE AMOUNT CALCULATED FROM THE

S. 5845                             5

AVERAGE TEN YEAR ROLLING AVERAGE INCREASE OF THE  MEDICAL  COMPONENT  OF
THE  CONSUMER  PRICE  INDEX.  This  paragraph  shall not be construed as
limiting the benefits that are  otherwise  available  to  an  individual
under  the  [policy]  CONTRACT,  provided  however  that  such  [policy]
CONTRACT shall not contain any limitations on  visits  that  are  solely
applied  to  the treatment of autism spectrum disorder. No insurer shall
terminate coverage or refuse to deliver, execute, issue, amend,  adjust,
or  renew  coverage  to  an  individual solely because the individual is
diagnosed with autism spectrum disorder or has  received  treatment  for
autism  spectrum  disorder.  Coverage  shall  be  subject to utilization
review and external appeals of health care services pursuant to  article
forty-nine  of  this  chapter  as  well  as,  case management, and other
managed care provisions.
  (3) For purposes of this subsection:
  (A) "autism  spectrum  disorder"  means  any  pervasive  developmental
disorder  as  defined  in  the most recent edition of the diagnostic and
statistical manual of mental  disorders,  including  autistic  disorder,
Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
or pervasive developmental disorder not otherwise specified (PDD-NOS).
  (B)  "applied behavior analysis" means the design, implementation, and
evaluation of environmental modifications, using behavioral stimuli  and
consequences,  to  produce  socially  significant  improvement  in human
behavior, including the use  of  direct  observation,  measurement,  and
functional  analysis  of the relationship between environment and behav-
ior.
  (C) "behavioral  health  treatment"  means  counseling  and  treatment
programs,  when  provided  by  a licensed provider, and applied behavior
analysis, when provided or supervised by a  behavior  analyst  certified
pursuant to the behavior analyst certification board, that are necessary
to develop, maintain, or restore, to the maximum extent practicable, the
functioning of an individual. Individuals that provide behavioral health
treatment under the supervision of a certified behavior analyst pursuant
to  this  subsection  shall  be subject to standards of professionalism,
SUPERVISION and relevant experience pursuant to regulations  promulgated
by  the  superintendent  in consultation with the [commissioner] COMMIS-
SIONERS of health AND EDUCATION.
  (D) "diagnosis of autism spectrum disorder" means assessments,  evalu-
ations,  or  tests to diagnose whether an individual has autism spectrum
disorder.
  (E) "pharmacy care" means medications prescribed by a licensed  health
care  provider  legally authorized to prescribe under title eight of the
education law.
  (F) "psychiatric care" means direct or consultative services  provided
by  a psychiatrist licensed in the state in which the psychiatrist prac-
tices.
  (G)  "psychological  care"  means  direct  or  consultative   services
provided  by  a psychologist licensed in the state in which the psychol-
ogist practices.
  (H) "therapeutic care" means services provided by licensed  or  certi-
fied  speech  therapists,  occupational  therapists,  social workers, or
physical therapists.
  (I) "treatment of autism spectrum disorder" shall include the  follow-
ing   care  and  [related  equipment]  ASSISTIVE  COMMUNICATION  DEVICES
prescribed or ordered for an individual diagnosed with  autism  spectrum
disorder by a licensed physician or a licensed psychologist:
  (i) behavioral health treatment;

S. 5845                             6

  (ii) psychiatric care;
  (iii) psychological care;
  (iv) medical care provided by a licensed health care provider;
  (v) therapeutic care, including therapeutic care which is deemed habi-
litative or nonrestorative, in the event that the policy provides cover-
age for therapeutic care; and
  (vi)  pharmacy  care  in the event that the [policy] CONTRACT provides
coverage for prescription drugs.
  (4) Coverage may be denied on the basis that such treatment  is  being
provided  to  the covered person pursuant to an individualized education
plan under article eighty-nine of the education law.  The  provision  of
services pursuant to an individualized family service plan under section
twenty-five  hundred forty-five of the public health law, an individual-
ized education plan under article eighty-nine of the education  law,  or
an individualized service plan pursuant to regulations of the office for
persons  with developmental disabilities shall not affect coverage under
the policy for services provided on a supplemental basis outside  of  an
educational setting if such services are prescribed by a licensed physi-
cian or licensed psychologist.
  (5)  Nothing in this subsection shall be construed to affect any obli-
gation to provide services to  an  individual  under  an  individualized
family  service plan under section twenty-five hundred forty-five of the
public health law, an individualized education plan under article eight-
y-nine of the education law, or an individualized service plan  pursuant
to  regulations  of  the office for persons with developmental disabili-
ties.
  (6) Nothing in this subsection shall be construed to affect any  obli-
gation  to provide coverage for otherwise-covered services solely on the
basis that the services constitute early intervention  program  services
pursuant  to  section  three  thousand two hundred thirty-five-a of this
article or an individualized service plan pursuant to regulations of the
office for persons with developmental disabilities.
  (7) Nothing in this subsection shall be construed to prevent a  [poli-
cy]  CONTRACT from providing services through a network of participating
providers who shall meet certain requirements for participation, includ-
ing provider credentialing.
  S 4. Section 5 of a chapter of the laws of 2011 amending the insurance
law relating to coverage for the screening, diagnosis and  treatment  of
autism  spectrum  disorder,  as  proposed in legislative bill numbers S.
4005-A and A. 6305-A, is amended to read as follows:
  S 5. This act shall take effect [on the first of January next succeed-
ing the date on which] ONE YEAR AFTER it shall have  become  a  law  and
shall  apply  to  all  policies and contracts issued, renewed, modified,
altered or amended on or after such date.
  S 5. This act shall take effect immediately; provided,  however,  that
sections  one,  two  and three of this act shall take effect on the same
date and in the same manner as a chapter of the laws  of  2011  amending
the  insurance law relating to coverage for the screening, diagnosis and
treatment of autism spectrum disorder, as proposed in  legislative  bill
numbers S. 4005-A and A. 6305-A, takes effect.